Dissociative Identity Disorder

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Previously known as multiple personality disorder, dissociative identity disorder (DID) is a condition in which those affected have more than one distinct identity or personality state. At least two of these personalities repeatedly assert themselves to control the behavior of the affected people. Each personality state has a distinct name, past, identity, and self-image.

Psychiatrists and psychologists use a handbook called the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, or DSM-IV-TR, to diagnose mental disorders. In this handbook, DID is classified as a dissociative disorder. Other mental disorders in this category include depersonalization disorder, dissociative fugue , and dissociative amnesia. It should be noted, however, that the nature of DID and even its existence is debated by psychiatrists and psychologists.

Description

“Dissociation” describes a state in which the integrated functioning of a person’s identity, including consciousness, memory, and awareness of surroundings, is disrupted or eliminated. Dissociation is a mechanism that allows the mind to separate or compartmentalize certain memories or thoughts from normal consciousness. These memories are not erased, but are buried and may resurface at a later time. Dissociation is related to hypnosis in that hypnotic trance also involves a temporarily altered state of consciousness. In severe, impairing dissociation, individuals experience a lack of awareness of important aspects of their identities.

The phrase “dissociative identity disorder” replaced “multiple personality disorder” because the new name emphasizes the disruption of a person’s identity that characterizes the disorder. People with the illness are consciously aware of one aspect of their personality or self while being totally unaware of, or dissociated from, other aspects of it. This is a key feature of the disorder. It requires only two distinct identities or personality states to qualify as DID, but there have been cases in which 100 distinct alternate personalities, or alters, were reported. Fifty percent of patients with DID harbor fewer than 11 identities.

Because the alters alternate in controlling the consciousness and behavior of those affected, patients experience long gaps in memory—gaps that far exceed typical episodes of forgetting that occur in those unaffected by DID.

Despite the presence of distinct personalities, one primary identity exists in many cases. The primary identity uses the name the patient was born with and tends to be quiet, dependent, depressed, and guilt-ridden. The alters have their own names and unique traits. They are distinguished by different temperaments, likes, dislikes, manners of expression, and even physical characteristics such as posture and body language. It is not unusual for patients with DID to have alters of different genders, sexual orientations, ages, or nationalities. It typically takes just seconds for one personality to replace another but the shift can be gradual in rarer instances. In either case, the emergence of one personality, and the retreat of another, is often triggered by a stressful event.

People with DID tend to have other severe disorders as well, such as depression, substance abuse, borderline personality disorder , and eating disorders, among others. The degree of impairment ranges from mild to severe, and complications may include suicide attempts, self-mutilation, violence, or drug abuse.

Left untreated, DID can last a lifetime. Treatment for the disorder consists primarily of individual psychotherapy.

Causes and symptoms

Causes

The severe dissociation that characterizes patients with DID is currently understood to result from a set of causes:

• an innate ability to dissociate easily
• repeated episodes of severe physical or sexual abuse in childhood
• lack of supportive or comforting people to counteract abusive relative (s)
• influence of other relatives with dissociative symptoms or disorders

The primary cause of DID appears to be severe and prolonged trauma experienced during childhood. This trauma can be associated with emotional, physical, or sexual abuse, or some combination. One theory is that young children, faced with a routine of torture, sexual abuse, or neglect , dissociate themselves from their trauma by creating separate identities or personality states. Manufactured alters may suffer while primary identities “escape” the unbearable experiences. Dissociation, which is easy for young children to achieve, thus becomes a useful defense. This strategy displaces the suffering onto another identity. Over time, children, who on average are around six years old at the time of the appearance of the first alter, may create many more.

As stated, there is considerable controversy about the nature, and even the existence, of dissociative identity disorder. The causes are disputed, with some experts identifying extensive trauma in childhood as causative, while others maintain that the cause of the disorder is iatrogenic, or introduced by the news media or therapist. In this latter form, mass media or therapists plant the seeds that patients suppressed memories and dissociation severe enough to have created separate personalities. One cause for the skepticism is the alarming increase in reports of the disorder since the 1980s; more cases of DID were reported between 1981 and 1986 than in the previous 200 years combined. In some cases, people reporting DID and recovered memory became involved in lawsuits related to the recovered memories, only to find that the memories were not, in fact, real. Another disorder, false memory syndrome, then becomes the explanation. Thus, an area of contention is the notion of suppressed memories, a crucial component in DID. Many experts in memory research say that it is almost impossible for anyone to remember things that happened before the age of three, the age when some patients with DID supposedly experience abuse, but the brain’s storage, retrieval, and interpretation of childhood memories are still not fully understood. The relationship of dissociative disorders to childhood abuse has led to intense controversy and lawsuits concerning the accuracy of childhood memories. Because childhood trauma is a factor in the development of DID, some doctors think it may be a variation of post-traumatic stress disorder (PTSD). In both DID and PTSD, dissociation is a prominent mechanism.

Symptoms

The major dissociative symptoms experienced by patients with DID are amnesia, depersonalization , derealization, and identity disturbances.

AMNESIA

Amnesia in patients with DID is marked by gaps in their memory for long periods of their past, and, in some cases, their entire childhood. Most patients with DID have amnesia, or “lose time,” for periods when another personality is “out.” They may report finding items in their house that they cannot remember having purchased, finding notes written in different handwriting, or other evidence of unexplained activity.

DEPERSONALIZATION

Depersonalization is a dissociative symptom in which patients feel that their bodies are unreal, are changing, or are dissolving. Some patients with DID experience depersonalization as feeling outside of their bodies, or as watching a movie of themselves.

DEREALIZATION

Derealization is a dissociative symptom in which patients perceive the external environment as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. Patients with DID may fail to recognize relatives or close friends.

IDENTITY DISTURBANCES

People with DID usually have a main personality that psychiatrists refer to as the “host.” This is generally not the person’s original personality but is rather one developed in response to childhood trauma. It is usually this personality that seeks psychiatric help. Patients with DID are often frightened by their dissociative experiences, which can include losing awareness of hours or even days, meeting people who claim to know them by another name, or feeling “out of body.”

Psychiatrists refer to the phase of transition between alters as the “switch.” After a switch, people with DID assume whole new physical postures, voices, and vocabularies. Specific circumstances or stressful situations may bring out particular identities. Some patients have histories of erratic performance in school or in their jobs caused by the emergence of alternate personalities during examinations or other stressful situations. Each alternate identity takes control one at a time, denying control to the others. Patients vary with regard to their alters’ awareness of one another. One alter may not acknowledge the existence of others or it may criticize other alters. At times during therapy, one alter may allow another to take control.

Demographics

Studies in North America and Europe indicate that as many as 5% of patients in psychiatric wards have undiagnosed DID. Partially hospitalized patients and outpatients may have an even higher incidence. For every man diagnosed with DID, eight or nine women are diagnosed. Among children, boys and girls diagnosed with DID are pretty closely matched 1:1. No one is sure why this discrepancy between diagnosed adults and children exists.

Diagnosis

The DSM-IV-TR lists four diagnostic criteria for identifying DID and differentiating it from similar disorders:

• Traumatic stressor: Patients have been exposed to catastrophic events involving actual or threatened death or injury, or a serious physical threat to themselves or others. During exposure to the trauma, their emotional response was marked by intense fear, feelings of helplessness, or horror. In general, stressors caused intentionally by human beings (genocide, rape, torture, abuse, etc.) are experienced as more traumatic than accidents, natural disasters, or “acts of God.”
• The demonstration of two or more distinct identities or personality states in an individual. Each separate identity must have its own way of thinking about, perceiving, relating to, and interacting with the environment and self.
• Two of the identities assume control of the patient’s behavior, one at a time and repeatedly.
• Extended periods of forgetfulness lasting too long to be considered ordinary forgetfulness.
• Determination that the above symptoms are not due to drugs, alcohol, or other substances and that they cannot be attributed to any other general medical condition. It is also necessary to rule out fantasy play or imaginary friends when considering a diagnosis of DID in children.

Proper diagnosis of DID is complicated because some of the symptoms of DID overlap with symptoms of other mental disorders. Misdiagnoses are common and include depression, schizophrenia , borderline personality disorder, somatization disorder , and panic disorder.

Because the extreme dissociative experiences related to this disorder can be frightening, people with the disorder may go to emergency rooms or clinics because they fear they are going insane.

When a doctor is evaluating a patient for DID, the first step is to rule out physical conditions that

KEY TERMS

Alter —An alternate or secondary personality in a person with dissociative identity disorder. Each alter has a unique way of looking at and interacting with the world.

Amnesia —A general medical term for loss of memory that is not due to ordinary forgetfulness. Amnesia can be caused by head injuries, brain disease, or epilepsy, as well as by dissociation.

Borderline personality disorder —A severe and usually lifelong mental disorder characterized by violent mood swings and severe difficulties in sustaining interpersonal relationships.

Depersonalization —A dissociative symptom in which patients feel that their bodies are unreal, are changing, or are dissolving.

Derealization —A dissociative symptom in which the external environment is perceived as unreal.

>Dissociation —A reaction to trauma in which the mind splits off certain aspects of the traumatic event from conscious awareness. Dissociation can affect a patient’s memory, sense of reality, and sense of identity.

Dissociative identity disorder (DID) —Term that replaced multiple personality disorder. A condition in which two or more distinctive identities or personality states alternate in controlling a person’s consciousness and behavior.

Host —The dominant or main alter in a person with DID.

Hypnosis —The means by which a state of extreme relaxation and suggestibility is induced. Hypnosis is used to treat amnesia and identity disturbances that occur in people with dissociative disorders.

Malingering —Knowingly pretending to be physically or mentally ill to avoid some unpleasant duty or responsibility, or for economic benefit.

Multiple personality disorder (MPD) —An older term for dissociative identity disorder (DID).

Panic disorder —An anxiety disorder in which an individual experiences sudden, debilitating attacks of intense fear.

Post-traumatic stress disorder (PTSD) —A disorder caused by an extremely stressful or traumatic event (such as rape, act of war, or natural disaster), in which the trauma victim is haunted by flashbacks. In the flashbacks, the event is reexperienced in the present. Other symptoms include nightmares and feelings of anxiety.

Primary personality —The core personality of a patient with DID. In women, the primary personality is often timid and passive, and may be diagnosed as depressed.

Schizophrenia —A severe mental illness in which a person has difficulty distinguishing what is real from what is not real. It is often characterized by hallucinations, delusions, language and communication disturbances, and withdrawal from people and social activities.

Shift —The transition of control from one alter to another in a person with DID. Usually shifts occur rapidly, within seconds, but in some cases a more gradual changeover is observed. Also referred to as a switch.

Somatization disorder —A type of mental disorder in which the patient has physical complaints that serve as coping strategies for emotional distress.

Trauma —A disastrous or life-threatening event that can cause severe emotional distress. DID is associated with trauma in a person’s early life or adult experience.

sometimes produce amnesia, depersonalization, or derealization. These conditions include head injuries, brain disease (especially seizure disorders), side effects from medications, substance abuse or intoxication, AIDS dementia complex, or recent periods of extreme physical stress and sleeplessness. In some cases, the doctor may give the patient an electroencephalograph (EEG) to exclude epilepsy or other seizure disorders. The physician also must consider whether the patient is malingering and/or offering fictitious complaints.

If the patient appears to be physically healthy, the doctor will next rule out psychotic disturbances, including schizophrenia. Many patients with DID are misdiag-nosed as having schizophrenia because they may “hear” their alters “talking” inside their heads. Doctors who suspect DID can use a screening test called the Dissociative Experiences Scale (DES). Patients with high scores on this test can be evaluated further with the Dissociative Disorders Interview Schedule (DDIS) or the Structured Clinical Interview for Dissociative Disorders (SCID-D).

Treatments

Treatment of DID may last for five to seven years in adults and usually requires several different treatment methods.

Psychotherapy

Ideally, patients with DID should be treated by a therapist with specialized training in dissociation. This specialized training is important because the patient’s personality switches can be confusing or startling. In addition, many patients with DID have hostile or suicidal alter personalities. Most therapists who treat patients with DID have rules or contracts for treatment that include such issues as responsibility for the patient’s safety. Psychotherapy for patients with DID typically has several stages: an initial phase for uncovering and “mapping” the patient’s alters; a phase of treating the traumatic memories and “fusing” the alters; and a phase of consolidating the patient’s newly integrated personality.

Most therapists who treat multiples, or patients with DID, recommend further treatment after personality integration, on the grounds that the patients have not learned the social skills that most people acquire in adolescence and early adult life. In addition, family therapy is often recommended to help families understand DID and the changes that occur during personality reintegration.

Many patients with DID are helped by group therapy as well as individual treatment, provided that the group is limited to people with dissociative disorders. Patients with DID sometimes have setbacks in mixed therapy groups because other patients are bothered or frightened by their personality switches.

Medications

Some doctors will prescribe tranquilizers or antidepressants for patients with DID because their alter personalities may have anxiety or mood disorders. However, other therapists who treat patients with DID prefer to keep medications to a minimum because these patients can easily become psychologically dependent on drugs. In addition, many patients with DID have at least one alter who abuses drugs or alcohol, substances that are dangerous in combination with most tranquilizers.

Hypnosis

Although not always necessary, hypnosis (or hypnotherapy ) is a standard method of treatment for patients with DID. Hypnosis may help patients recover repressed ideas and memories. Further, hypnosis can also be used to control problematic behaviors that many patients with DID exhibit, such as self-mutilation, or eating disorders like bulimia nervosa. In the later stages of treatment, the therapist may use hypnosis to “fuse” the alters as part of the patient’s personality integration process.

Prognosis

Unfortunately, no systematic studies of the long-term outcome of DID currently exist. Some therapists believe that the prognosis for recovery is excellent for children and good for most adults. Although treatment takes several years, it is often ultimately effective. As a general rule, the earlier the patient is diagnosed and properly treated, the better the prognosis. Patients may find they are bothered less by symptoms as they advance into middle age, with some relief beginning to appear in the late 40s. Stress or substance abuse, however, can cause a relapse of symptoms at any time.

Prevention

Prevention of DID requires intervention in abusive families and treating children with dissociative symptoms as early as possible.

See alsoDissociation and dissociative disorders.

Resources

BOOKS

Acocella, Joan. Creating Hysteria: Women and Multiple Personality Disorder. San Francisco, CA: Jossey-Bass Publishers, 1999.

Alderman, Tracy, and Karen Marshall. Amongst Ourselves, A Self-Help Guide to Living with Dissociative Identity Disorder. Oakland, CA: New Harbinger Publications, 1998.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Saks, Elyn R., and Stephen H. Behnke. Jekyll on Trial, Multipersonality Disorder and Criminal Law. New York: New York University Press, 1997.

PERIODICALS

Gleaves, D. H., M. C. May, and E. Cardena. “An Examination of the Diagnostic Validity of Dissociative Identity Disorder.” Clinical Psychology Review 21.4 (June 2001): 577–608.

Lalonde, J. K., and others. “Canadian and American Psychiatrists’ Attitudes Toward Dissociative Disorders Diagnoses.” Canadian Journal of Psychiatry 46.5 (June 2001): 407–12.

Spitzer, Carsten, and others. “Recent Developments in the Theory of Dissociation.” World Psychiatry 5 (2006): 82–86.

Stickley, T., and R. Nickeas. “Becoming One Person: Living with Dissociative Identity Disorder.” Journal of Psychiatric and Mental Health Nursing 13 (2006): 180–87.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Telephone: (888) 357-7924. Fax: (202) 682-6850.

International Society for the Study of Dissociation. 60 Revere Drive, Suite 500, Northbrook, IL 60062. <http://www.issd.org/>.

National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22021. <http://www.nami.org/helpline/did.html>.

OTHER

The Mayo Clinic. “Dissociative Disorders.” <http://www.mayoclinic.com/health/dissociative-disorders/DS00574/DSECTION=5>.

Merck Manual for Healthcare Professionals. The Merck Manuals Online Medical Library. “Dissociative Identity Disorder.” 2005.

Rebecca J. Frey, PhD

Dean A. Haycock, PhD

Emily Jane Willingham, PhD

Dissociative identity disorder

Definition

Previously known as multiple personality disorder, dissociative identity disorder (DID) is a condition in which a person has more than one distinct identity or personality state. At least two of these personalities repeatedly assert themselves to control the affected person's behavior. Each personality state has a distinct name, past, identity, and self-image.

Psychiatrists and psychologists use a handbook called the Diagnostic and Statistical Manual of Mental Disorders , fourth edition text revision or DSM-IV-TR, to diagnose mental disorders. In this handbook, DID is classified as a dissociative disorder. Other mental disorders in this category include depersonalization disorder , dissociative fugue , and dissociative amnesia . It should be noted, however, that the nature of DID and even its existence is debated by psychiatrists and psychologists.

Description

"Dissociation" describes a state in which the integrated functioning of a person's identity, including consciousness, memory and awareness of surroundings, is disrupted or eliminated. Dissociation is a mechanism that allows the mind to separate or compartmentalize certain memories or thoughts from normal consciousness. These memories are not erased, but are buried and may resurface at a later time. Dissociation is related to hypnosis in that hypnotic trance also involves a temporarily altered state of consciousness. Dissociation occurs along a continuum or spectrum, and may be mild and part of the range of normal experience, or may be severe and pose a problem for the individual experiencing the dissociation. An example of everyday, mild dissociation is when a person is driving for a long period on the highway and takes several exits without remembering them. In severe, impairing dissociation, an individual experiences a lack of awareness of important aspects of his or her identity.

The phrase "dissociative identity disorder" replaced "multiple personality disorder" because the new name emphasizes the disruption of a person's identity that characterizes the disorder. A person with the illness is consciously aware of one aspect of his or her personality or self while being totally unaware of, or dissociated from, other aspects of it. This is a key feature of the disorder. It only takes two distinct identities or personality states to qualify as DID but there have been cases in which 100 distinct alternate personalities, or alters, were reported. Fifty percent of DID patients harbor fewer than 11 identities.

Because the alters alternate in controlling the patient's consciousness and behavior, the affected patient experiences long gaps in memory— gaps that far exceed typical episodes of forgetting that occur in those unaffected by DID.

Despite the presence of distinct personalities, in many cases one primary identity exists. It uses the name the patient was born with and tends to be quiet, dependent, depressed and guilt-ridden. The alters have their own names and unique traits. They are distinguished by different temperaments, likes, dislikes, manners of expression and even physical characteristics such as posture and body language. It is not unusual for patients with DID to have alters of different genders, sexual orientations, ages, or nationalities. Typically, it takes just seconds for one personality to replace another but, in rarer instances, the shift can be gradual. In either case, the emergence of one personality, and the retreat of another, is often triggered by a stressful event.

People with DID tend to have other severe disorders as well, such as depression, substance abuse, borderline personality disorder and eating disorders, among others. The degree of impairment ranges from mild to severe, and complications may include suicide attempts, self-mutilation, violence, or drug abuse.

Left untreated, DID can last a lifetime. Treatment for the disorder consists primarily of individual psychotherapy .

Causes and symptoms

Causes

The severe dissociation that characterizes patients with DID is currently understood to result from a set of causes:

• an innate ability to dissociate easily
• repeated episodes of severe physical or sexual abuse in childhood
• lack of a supportive or comforting person to counteract abusive relative(s)
• influence of other relatives with dissociative symptoms or disorders

The primary cause of DID appears to be severe and prolonged trauma experienced during childhood. This trauma can be associated with emotional, physical or sexual abuse, or some combination. One theory is that young children, faced with a routine of torture, sexual abuse or neglect , dissociate themselves from their trauma by creating separate identities or personality states. A manufactured alter may suffer while the primary identity "escapes" the unbearable experience. Dissociation, which is easy for a young child to achieve, thus becomes a useful defense. This strategy displaces the suffering onto another identity. Over time, the child, who on average is around six years old at the time of the appearance of the first alter, may create many more.

As stated, there is considerable controversy about the nature, and even the existence, of dissociative identity disorder. One cause for the skepticism is the alarming increase in reports of the disorder since the 1980s. An area of contention is the notion of suppressed memories, a crucial component in DID. Many experts in memory research say that it is nearly impossible for anyone to remember things that happened before the age three, the age when some DID patients supposedly experience abuse, but the brain's storage, retrieval, and interpretation of childhood memories are still not fully understood. The relationship of dissociative disorders to childhood abuse has led to intense controversy and lawsuits concerning the accuracy of childhood memories. Because childhood trauma is a factor in the development of DID, some doctors think it may be a variation of post-traumatic stress disorder (PTSD). In both DID and PTSD, dissociation is a prominent mechanism.

Symptoms

The major dissociative symptoms experienced by DID patients are amnesia , depersonalization , derealization, and identity disturbances.

AMNESIA. Amnesia in DID is marked by gaps in the patient's memory for long periods of their past, and, in some cases, their entire childhood. Most DID patients have amnesia, or "lose time," for periods when another personality is "out." They may report finding items in their house that they can't remember having purchased, finding notes written in different handwriting, or other evidence of unexplained activity.

DEPERSONALIZATION. Depersonalization is a dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving. Some DID patients experience depersonalization as feeling to be outside of their body, or as watching a movie of themselves.

DEREALIZATION. Derealization is a dissociative symptom in which the patient perceives the external environment as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. DID patients may fail to recognize relatives or close friends.

IDENTITY DISTURBANCES. Persons suffering from DID usually have a main personality that psychiatrists refer to as the "host." This is generally not the person's original personality, but is rather one developed in response to childhood trauma. It is usually this personality that seeks psychiatric help. DID patients are often frightened by their dissociative experiences, which can include losing awareness of hours or even days, meeting people who claim to know them by another name, or feeling "out of body."

Psychiatrists refer to the phase of transition between alters as the "switch." After a switch, people assume whole new physical postures, voices, and vocabularies. Specific circumstances or stressful situations may bring out particular identities. Some patients have histories of erratic performance in school or in their jobs caused by the emergence of alternate personalities during examinations or other stressful situations. Each alternate identity takes control one at a time, denying control to the others. Patients vary with regard to their alters' awareness of one another. One alter may not acknowledge the existence of others or it may criticize other alters. At times during therapy, one alter may allow another to take control.

Demographics

Studies in North America and Europe indicate that as many as 5% of patients in psychiatric wards have undiagnosed DID. Partially hospitalized and out-patients may have an even higher incidence. For every one man diagnosed with DID, there are eight or nine women. Among children, boys and girls diagnosed with DID are pretty closely matched 1:1. No one is sure why this discrepancy between diagnosed adults and children exists.

Diagnosis

The DSM-IV-TR lists four diagnostic criteria for identifying DID and differentiating it from similar disorders:

• Traumatic stressor: The patient has been exposed to a catastrophic event involving actual or threatened death or injury, or a serious physical threat to him- or herself or others. During exposure to the trauma, the person's emotional response was marked by intense fear, feelings of helplessness, or horror. In general, stressors caused intentionally by human beings (genocide, rape, torture, abuse, etc.) are experienced as more traumatic than accidents, natural disasters, or "acts of God."
• The demonstration of two or more distinct identities or personality states in an individual. Each separate identity must have its own way of thinking about, perceiving, relating to and interacting with the environment and self.
• Two of the identities assume control of the patient's behavior, one at a time and repeatedly.
• Extended periods of forgetfulness lasting too long to be considered ordinary forgetfulness.
• Determination that the above symptoms are not due to drugs, alcohol or other substances and that they can't be attributed to any other general medical condition. It is also necessary to rule out fantasy play or imaginary friends when considering a diagnosis of DID in a child.

Proper diagnosis of DID is complicated because some of the symptoms of DID overlap with symptoms of other mental disorders. Misdiagnoses are common and include depression, schizophrenia , borderline personality disorder, somatization disorder , and panic disorder .

Because the extreme dissociative experiences related to this disorder can be frightening, people with the disorder may go to emergency rooms or clinics because they fear they are going insane.

When a doctor is evaluating a patient for DID, he or she will first rule out physical conditions that sometimes produce amnesia, depersonalization, or derealization. These conditions include head injuries, brain disease (especially seizure disorders), side effects from medications, substance abuse or intoxication, AIDS dementia complex, or recent periods of extreme physical stress and sleeplessness. In some cases, the doctor may give the patient an electroencephalograph (EEG) to exclude epilepsy or other seizure disorders. The physician also must consider whether the patient is malingering and/or offering fictitious complaints.

If the patient appears to be physically healthy, the doctor will next rule out psychotic disturbances, including schizophrenia. Many patients with DID are misdiagnosed as schizophrenic because they may "hear" their alters "talking" inside their heads. If the doctor suspects DID, he or she can use a screening test called the Dissociative Experiences Scale (DES). If the patient has a high score on this test, he or she can be evaluated further with the Dissociative Disorders Interview Schedule (DDIS) or the Structured Clinical Interview for Dissociative Disorders (SCID-D).

Treatments

Treatment of DID may last for five to seven years in adults and usually requires several different treatment methods.

Psychotherapy

Ideally, patients with DID should be treated by a therapist with specialized training in dissociation. This specialized training is important because the patient's personality switches can be confusing or startling. In addition, many patients with DID have hostile or suicidal alter personalities. Most therapists who treat DID patients have rules or contracts for treatment that include such issues as the patient's responsibility for his or her safety. Psychotherapy for DID patients typically has several stages: an initial phase for uncovering and "mapping" the patient's alters; a phase of treating the traumatic memories and "fusing" the alters; and a phase of consolidating the patient's newly integrated personality.

Most therapists who treat multiples, or DID patients, recommend further treatment after personality integration, on the grounds that the patient has not learned the social skills that most people acquire in adolescence and early adult life. In addition, family therapy is often recommended to help the patient's family understand DID and the changes that occur during personality reintegration.

Many DID patients are helped by group therapy as well as individual treatment, provided that the group is limited to people with dissociative disorders. DID patients sometimes have setbacks in mixed therapy groups because other patients are bothered or frightened by their personality switches.

Medications

Some doctors will prescribe tranquilizers or antidepressants for DID patients because their alter personalities may have anxiety or mood disorders. However, other therapists who treat DID patients prefer to keep medications to a minimum because these patients can easily become psychologically dependent on drugs. In addition, many DID patients have at least one alter who abuses drugs or alcohol, substances which are dangerous in combination with most tranquilizers.

Hypnosis

While not always necessary, hypnosis (or hypnotherapy ) is a standard method of treatment for DID patients. Hypnosis may help patients recover repressed ideas and memories. Further, hypnosis can also be used to control problematic behaviors that many DID patients exhibit, such as self-mutilation, or eating disorders like bulimia nervosa . In the later stages of treatment, the therapist may use hypnosis to "fuse" the alters as part of the patient's personality integration process.

Prognosis

Unfortunately, no systematic studies of the long-term outcome of DID currently exist. Some therapists believe that the prognosis for recovery is excellent for children and good for most adults. Although treatment takes several years, it is often ultimately effective. As a general rule, the earlier the patient is diagnosed and properly treated, the better the prognosis. Patients may find they are bothered less by symptoms as they advance into middle age, with some relief beginning to appear in the late 40s. Stress or substance abuse, however, can cause a relapse of symptoms at any time.

Prevention

Prevention of DID requires intervention in abusive families and treating children with dissociative symptoms as early as possible.

See also Dissociation and dissociative disorders

Resources

BOOKS

Acocella, Joan. Creating Hysteria: Women and Multiple Personality Disorder. San Francisco, CA: Jossey-Bass Publishers, 1999.

Alderman, Tracy, and Karen Marshall. Amongst Ourselves, A Self-Help Guide to Living with Dissociative Identity Disorder. Oakland, CA: New Harbinger Publications, 1998.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Saks, Elyn R., with Stephen H. Behnke. Jekyll on Trial, Multipersonality Disorder and Criminal Law. New York, NY: New York University Press, 1997.

PERIODICALS

Gleaves, D. H., M. C. May, and E. Cardena. "An examination of the diagnostic validity of dissociative identity disorder." Clinical Psychology Review 21, no. 4 (June 2001): 577-608.

Lalonde, J. K., J. I. Hudson, R. A. Gigante, H. G. Pope, Jr. "Canadian and American psychiatrists' attitudes toward dissociative disorders diagnoses." Canadian Journal of Psychiatry 46, no. 5 (June 2001): 407-12.

ORGANIZATIONS

International Society for the Study of Dissociation, 60 Revere Dr., Suite 500, Northbrook, IL 60062. <http://www.issd.org/>.

National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington,VA 22021. <http://www.nami.org/helpline/did.html>.

Rebecca J. Frey, Ph.D.

Dean A. Haycock, Ph.D.

Dissociative Identity Disorder

What Is Dissociative Identity Disorder?

Is Dissociative Identity Disorder a Real Disorder?

How Is Dissociative Identity Disorder Diagnosed?

How is Dissociative Identity Disorder Treated?

Resources

Dissociative (di-SO-see-a-tiv) identity disorder (DID) is a severe mental disorder in which a person has two or more distinct sub-personalities that periodically take control of the person’s behavior. Before 1994, DID was called multiple personality disorder (MPD).

KEYWORDS

for searching the Internet and other reference sources

Child abuse

Dissociative disorders

Identity

Memory

Multiple personality disorder (MPD)

Stress

What Is Dissociative Identity Disorder?

Dissociative identity disorder (DID) is the most complex of a group of disorders characterized by the process of dissociation (di-SO-see-ay-shun). Other dissociative disorders include amnesia*, fugue*, and depersonalization*. Dissociation is a defense mechanism that allows an individual to separate or “go away from” thoughts, memories, emotions, or events that are highly stressful. This process helps the individual deal with situations that would otherwise be intolerable. Because dissociation is an unconscious process, the person experiencing it is not aware of any personality changes that occur during an episode.

* amnesia

(am-NEE-zha) is the loss of memory about one or more past experiences that is more than normal forgetfulness.

* fugue

(FYOOG) refers to a psychiatric condition in which people wander or travel and may appear to be functioning normally, but they are unable to remember their identity or details about their past.

* depersonalization

(de-per-sonal-i-ZAY-shun) is a mental condition in which people feel that they are living in a dream or are removed from their body and are watching themselves live.

Mentally healthy people often experience mild forms of dissociation, such as daydreaming or getting lost in a book or a movie. Most people, especially adolescents, also find that different aspects of their personality tend to come out in certain situations or with certain groups of people. These changes in personality are normal.

DID, however, involves extreme and repeated dissociation that interferes with a person’s normal functioning and can result in memory gaps and identity confusion. By repeatedly dissociating and blocking out painful or unpleasant memories, a person with DID develops two or more distinctly different, often colorful or dramatic, identities. People with DID may have between 10 and 15 sub-personalities, and some people may even have more than 100. Often these sub-personalities can differ in gender, style, voice, and psychological make-up. People with DID may discover unfamiliar articles in their homes that they have purchased while their behavior was controlled by a different sub-personality, and they may have conversations when one sub-personality is dominant that other sub-personalities cannot remember. Some life events and memories (particularly traumatic ones) are known to certain sub-personalities but remain unknown to others.

Is Dissociative Identity Disorder a Real Disorder?

The diagnosis of DID is the subject of controversy in the psychiatric community, Throughout history there are records of the occasional dissociated person who has behaved oddly. These people often have been described as “possessed,” and later they have been unable to recall their behavior during the possession. In some cultures, these people are still considered possessed, and they are treated with exorcisms to drive out the demons that control them. However, prior to 1980, multiple personality disorder (MPD), as DID was then called, was considered to be a rare psychiatric disorder; only a few hundred cases in several centuries of recorded medical literature had been documented.

In 1956, a fictionalized story (later made into a movie) called The Three Faces of Eve helped introduce the public to the idea of MPD. In 1973, the subject was brought before the public again with a documentary, Sybil, which portrayed a woman with 16 different personalities. Since then, some psychiatrists have questioned the accuracy of the Sybil story. However, since about 1980 the number of people diagnosed with DID has increased sharply, and some psychiatrists estimate that as many as 1 and 3 percent of Americans may suffer from the disorder.

There are two different schools of thought about the DID:

DID is a common and serious disorder

One group of psychiatric professionals recognizes DID as a common and serious psychiatric disorder. They believe that DID is caused by repeated severe physical, emotional, or sexual trauma or abuse in early childhood. Children find these experiences too terrible to remember, so they repress them and mentally “go away” in order to cope with daily life. Later, these traumatized children develop multiple sub-personalities to deal with the repressed memories. When under stress in adulthood, certain triggers cause the switching from one sub-personality to another as a way of coping. The sub-personalities may have different psychological problems and may even have different physical traits. They may even have distinctive handwriting or different allergies!

Psychiatrists who support DID as a common disorder point to the fact that child abuse is common, and because dissociation is a very effective coping tool for people who are powerless to change their situations, DID is therefore also likely to be genuine and common.

DID rarely develops independently

A second group of psychiatric professionals thinks that DID rarely develops on its own in a person. They believe that DID is unknowingly created by interactions between the therapist and the patient when patients are highly susceptible to the suggestions of the therapist. This group of psychiatrists believes that in some cases therapy causes patients to recover memories of abuse that did not really happen and to unconsciously invent sub-personalities. Because the abuse that is supposed to cause DID happens in early childhood, it is often impossible to confirm any trauma that the patient describes.

This doubting group of psychiatrists points out that symptoms of DID are detected by friends or family members only after therapy has begun. They note that DID is rarely seen in children, and that many children who survive stressful events such as extreme abuse, war, kidnapping, or genocide do not suffer from DID.

The validity of recovered memories is highly controversial. Psychiatrists are divided on whether recovered memories, especially those recovered under hypnosis, are real or if they have been unwittingly suggested to the person through therapy, news stories, or ideas they have gotten from relatives or loved ones. This complicates the issue of whether DID is caused by early childhood trauma and abuse. Almost all (98 to 99 percent) of people diagnosed with DID seem to have experienced severe trauma before age nine. However, only a small percentage of all people who experience documented childhood trauma develop DID.

How Is Dissociative Identity Disorder Diagnosed?

DID is difficult to diagnose. People with DID have distinct multiple sub-personalities, but within each sub-personality they tend to be consistent. To diagnose DID, a doctor must see two or more distinct sub-personalities that each become dominant for a period of time. Sometimes doctors use hypnosis to try to bring out different sub-personalities.

People with DID can also have many other symptoms. Almost every person who has been diagnosed with DID has been in the mental health system for a long time (an average of seven years in one study) and has had previous, presumably incorrect, diagnoses before a diagnosis of DID is made. People with DID usually show signs of other psychiatric and/or physical disorders, including amnesia, time loss, depression*, severe mood swings, sleep disorders, alcoholism, drug dependency, panic attacks*, anxiety*, phobias*, auditory and/or visual hallucinations*, eating disorders*, headaches, trances, and violence toward themselves or others. It takes careful evaluation over time to understand whether certain symptoms indicate DID or other conditions.

* depression

(de-PRESH-un) is a mental state characterized by feelings of sadness, despair, and discouragement.

* panic attacks

are periods of intense fear or discomfort with a feeling of doom and a desire to escape. During a panic attack, a person may shake, sweat, be short of breath, and experience chest pain.

* anxiety

(ang-ZY-e-tee) can be experienced as a troubled feeling, a sense of dread, fear of the future, or distress over a possible threat to a person’s physical or mental well-being.

* phobias

(FO-be-as) are intense, persistent fears of a particular thing or situation.

* hallucinations

(huh-LOO-sinAY-shuns) are things that a person perceives as real but that are not actually caused by an outside event. They can involve any of the senses: hearing, smell, sight, taste, or touch.

* eating disorders

are conditions in which a person’s eating behaviors and food habits are so unbalanced that they cause physical and emotional problems.

DID differs from schizophrenia* and psychosis*, although they all may share some symptoms. Schizophrenia is not a “split personality” (like the fictional Dr. Jekyll and Mr. Hyde), but a disorder of reality and thought. Unlike people with schizophrenia, people with DID are in full control of their thoughts, although they may be unable to remember large portions of their life when their behavior is being controlled by a different sub-personality. Unlike people with psychosis, who often have visual or auditory hallucinations, people with DID generally do not have bizarre, uncontrolled thoughts or serious problems in how they sense reality. Within each sub-personality a person with DID may function well.

* schizophrenia

(skit-so-FRE-ne-a) is a serious mental disorder that causes people to experience hallucinations, delusions, and other confusing thoughts and behaviors, which distort their view of reality.

* psychosis

(sy-KO-sis) refers to mental disorders in which the sense of reality is so impaired that a patient can not function normally. People with psychotic disorders may experience delusions, hallucinations, incoherent speech, and agitated behavior, but they usually are not aware of their altered mental state.

How is Dissociative Identity Disorder Treated?

Therapists who believe that DID is brought about by childhood trauma use a technique called integrative psychotherapy*. This form of therapy involves recovering repressed or dissociated childhood memories and making them a part of a single personality in order to help the person become whole and reengage with the world. Often this process is emotionally painful because it involves facing past trauma. The use of hypnosis

* psychotherapy

(sy-ko-THER-apea) is the treatment of mental and behavioral disorders by support and insight to encourage healthy behavior patterns and personality growth.

to recover memories of childhood trauma is controversial and not accepted by all mental health professionals. Therapists who believe that DID is unknowingly created in susceptible patients by well-meaning therapists believe that the correct treatment is to discontinue therapy. Both groups agree that medication does not often help the dissociation that occurs in people with DID, but it may help with other symptoms.

See also

Amnesia

Fugue

Hypnosis

Phobias

Psychosis

Schizophrenia

Stress

Resources

Book

Schreiber, Flora Rhea. Sybil. New York: Warner Books, 1974.

Organization

The National Alliance for the Mentally Ill (NAMI) is a nonprofit organization that provides education, support, and advocacy for people with severe mental illnesses and their families. NAMI’s website provides information about many mental illnesses, including DID. Telephone 800-950-NAMI http:/www.nami.org

Dissociative identity disorder

Also referred to as multiple personality disorder, a condition in which a person's identity dissociates, or fragments, creating additional, distinct identities that exist independently of each other within the same person.

Persons suffering from dissociative identity disorder (DID) adopt one or more distinct identities which co-exist within one individual. Each personality is distinct from the other in specific ways. For instance, tone of voice and mannerisms will be distinct, as well as posture, vocabulary, and everything else we normally think of as marking a personality. There are cases in which a person will have as many as 100 or more identities, while some people only exhibit the presence of one or two. In either case, the criteria for diagnosis are the same. This disorder was, until the publication of DSMIV, referred to as multiple personality disorder. This name was abandoned for a variety of reasons, one having to do with psychiatric explicitness (it was thought that the name should reflect the dissociative aspect of the disorder).

The DSM-IV lists four criteria for diagnosing someone with dissociative identity disorder. The first being the presence of two or more distinct "identities or personality states." At least two personalities must take control of the person's identity regularly. The person must exhibit aspects of amnesia—that is, he or she forgets routine personal information. And, finally, the condition must not have been caused by "direct physiological effects," such as drug abuse or head trauma.

Persons suffering from DID usually have a main personality that psychiatrists refer to as the "host." This is generally not the person's original personality, but is rather developed along the way. It is usually this personality that seeks psychiatric help. Psychiatrists refer to the other personalities as "alters" and the phase of transition between alters as the "switch." The number of alters in any given case can vary widely and can even vary across gender. That is, men can have female alters and women can have male alters. The physical changes that occur in a switch between alters is one of the most baffling aspects of dissociative identity disorder. People assume whole new physical postures and voices and vocabularies. One study conducted in 1986 found that in 37 percent of patients, alters even demonstrated different handedness from the host.

Statistically, sufferers of DID have an average of 15 identities. The disorder is far more common among females than males (as high as 9-to-1), and the usual age of onset is in early childhood , generally by the age of four. Once established, the disorder will last a lifetime if not treated. New identities can accumulate over time as the person faces new types of situations. For instance, as a sufferer confronts sexuality in adolescence , an identity may emerge that deals exclusively with this aspect of life. There are no reliable figures as to the prevalence of this disorder, although it has begun to be reported with increased frequency over the last several years. People with DID tend to have other severe disorders as well, such as depression , substance abuse, borderline personality disorder and eating disorders , among others.

In nearly every case of DID, horrific instances of physical or sexual child abuse—even torture—was present (one study of 100 DID patients found that 97 had suffered child abuse ). It is believed that young children, faced with a routine of torture and neglect, create a fantasy world in order to escape the brutality. In this way, DID is similar to post-traumatic stress disorder , and recent thinking in psychiatry has suggested that the two disorders may be linked; some are even beginning to view DID as a severe subtype of post-traumatic stress disorder.

Treatment of dissociative identity disorder is a long and difficult process, and success (the complete integration of identity) is rare. A 1990 study found that of 20 patients studied, only five were successfully treated. Current treatment method involves having DID patients recall the memories of their childhoods. Because these childhood memories are often subconscious, treatment often includes hypnosis to help the patient remember. There is a danger here, however, as sometimes the recovered memories are so traumatic for the patient that they cause more harm.

TWO FAMOUS CASES

The stories of two women with multiple personality disorders have been told both in books and films. A woman with 22 personalities was recounted in 1957 in a major motion picture staring Joanne Woodward and in a book by Corbett Thigpen, both titled the Three Faces of Eve. Twenty years later, in 1977, Caroline Sizemore, the 22nd personality to emerge in "Eve," described her experiences in a book titled I'm Eve. Although the woman known as "Eve" developed a total of 22 personalities, only three could exist at any one time—for a new one to emerge, an existing personality would "die."

The story of Sybil (a pseudonym) was published in 1973 by Flora Rheta Schreiber, who worked closely for a decade with Sybil and her New York psychiatrist Dr. Cornelia B. Wilbur. Sybil's sixteen distinct personalities emerged over a period of 40 years.

Both stories reveal fascinating insights—and raise thought-provoking questions—about the unconscious mind, the interrelationship between remembering and forgetting, and the meaning of personality development. The separate and distinct personalities manifested in these two cases feature unique physical traits and vocational interests. In the study of this disorder, scientists have been able to monitor unique patterns of brainwave activity for the unique multiple personalities.

There is considerable controversy about the nature, and even the existence, of dissociative identity disorder. One cause for the skepticism is the alarming increase in reports of the disorder over the last several decades. Eugene Levitt, a psychologist at the Indiana University School of Medicine, noted in an article published in Insight on the News (1993) that "In 1952 there was no listing for [DID] in the DSM, and there were only a handful of cases in the country. In 1980, the disorder [then known as multiple personality disorder] got its official listing in the DSM, and suddenly thousands of cases are springing up everywhere." Another area of contention is in the whole notion of suppressed memories, a crucial component in DID. Many experts dealing with memory say that it is nearly impossible for anyone to remember things that happened before the age three, the age when much of the abuse supposedly occurred to DID sufferers.

Regardless of the controversy, people diagnosed with this disorder are clearly suffering from some profound disorder. As Helen Friedman, a clinical psychologist in St. Louis told Insight on the News, "When you see it, it's just not fake."

Further Reading

Arbetter, Sandra. "Multiple Personality Disorder: Someone Else Lives Inside of Me." Current Health (2 November 1992): 17.

Mesic, Penelope. "Presence of Minds." Chicago (September 1992): 100.

Sileo, Chi Chi. "Multiple Personalities: The Experts Are Split." Insight on the News (25 October 1993): 18. Sizemore, Chris Costner. I'm Eve. Garden City, NY: Doubleday, 1977.

Sybil [video recording].

Thigpen, Corbett H. The Three Faces of Eve. New York: Popular Library, 1957.

The Three Faces of Eve [videorecording]. Beverly Hills, CA: Fox Video, 1993. Produced and directed from his screenplay by Nunnally Johnson. Originally released as motion picture in 1957.

"When the Body Remembers." Psychology Today (April 1994): 9.